Chapter 8.  Field Work in Seven States

This chapter summarizes the field work conducted as part of this study. It includes the following subsections:

• The Field Work Process
• Observations from the Fieldwork
• Conclusions

Additional details about the conduct of the fieldwork and more details from the various interviews and meetings are provided in Appendix G.

As a part of this study, fieldwork was conducted in seven States chosen for their geographic diversity and for the variety of legal and regulatory climates they have for the professions. The States chosen were California, Illinois, New York, North Carolina, Ohio, Oregon and Texas. These States represent variation in demographics, geography, and composition of health care delivery programs. Of particular interest was the impact of the three professions on delivery of care to underserved populations.

The visits to California, Ohio, and New York were conducted by Albany Center. The visits in Oregon were conducted by the WWAMI Center for Health Workforce Studies. The visits in Illinois were conducted by the Illinois Center for Health Workforce Studies. The visits in Texas were conducted by the Center for Health Economics and Policy at the University of Texas Health Science Center at San Antonio. The visits in North Carolina were conducted by the North Carolina Center for Nursing.

The field work was conducted in a variety of formats. Focus groups were convened in State capitals, large urban settings, and in rural locations across the fieldwork States to discuss legal and professional practice issues for the three professions. In some cases, one-on-one face-to-face or telephone interviews were conducted, and in others, written communication was involved.

The fieldwork was structured by a list of questions generated by the cooperating research centers and by the Project Advisory Committee that was convened to monitor and direct the study process. A list of those questions is provided in Appendix H. Individual State fieldwork reports relied on a variety of published data for background information on the supply of the professions within States, the educational programs available to the professions, the numbers of recent graduates from those educational programs, and the demographics of the States involved.  The findings of the fieldwork relied heavily on the observations of those who provided insights to the discussions about the professional experience of NPs, CNMs, and PAs in the various States.

Those interviewed in the fieldwork included State legislators and government regulators, State and local policymakers, educators of the three professions, representatives of primary care coordinating councils and area health education centers, representatives of the physician, nurse practitioner, certified nurse midwife, and physician assistant professions, and the directors and staff of community health clinics, mobile clinics, hospital systems, long term care facilities, and rural health projects. Participants were identified through a variety of means including identification by the Project Advisory Committee, professional associations, and educational programs, as well as through Internet resources and literature searches, and personal referrals. Although the general experience of the field work staff was that the medical profession was underrepresented in the fieldwork process, physicians were invited to participate in all venues in all seven States. Participants in the focus groups and interviews represented a wide range of constituents and provided broad perspectives on the professions and their contributions to health care delivery.

In most cases, fieldwork was conducted at defined locations through formal invitations by project staff. Discussions were structured to last over a morning or afternoon session and generally involved mixed groups of participants. However, the composition of the groups varied. For instance, in New York City, individual professional focus groups were hosted that included only nurse practitioners in one session, physician assistants in another, and certified nurse midwives in a third. In other locations, participants included representatives from a range of professional, regulatory, and organizational groups. One center found that individual physician interviews were the most convenient way to obtain the insights from that constituent group.

The following bullets summarize interesting themes that emerged in the fieldwork discussions across States. These ideas are discussed in detail in the ensuing pages.

• Change in professional practice is often motivated by the practical experiences of the three professions and the physicians with whom they work. When a particular legal requirement becomes untenable in the practice environment, there is motivation by professional associations to advocate for change in the legislative arena. When advocates for patient groups feel that a situation is not acceptable, legislative initiatives are also forthcoming. Change appears to occur incrementally and often occurs through limited legislative mandates that sunset or expand at legislative review.
• The three professions are seeking recognition for their professional competencies and for the quality of care that they provide in an environment that is striving to use resources effectively and efficiently.
• The three professions resist the image of the professions as “cost-effective” providers, preferring instead to focus on their competencies and their contributions to healthcare for a variety of populations.
• The professional status of NPs, PAs, and CNMs has been enhanced by the increase in their numbers throughout the United States, by their employment in a wide range of healthcare settings that has increased their exposure to the public, and by increased scopes of practice including increased prescriptive authority which has allowed them to practice more “autonomously”.
• The professional scopes of practice of the three professions converged across the 50 States in the 1990s, consistent with statistical evidence presented earlier in this report.
• The most important professional practice issue for NPs and CNMs is reimbursement.
• Expanded prescriptive authority is the most important professional practice issue for physician assistants, and it is a concern of CNMs and NPs in certain States.
• There is a strong desire within the professions for increased visibility and acceptance by other providers, peers, patients, and payers.
• It is difficult to evaluate the contributions of the three professions to access to care because of the business practices and organizational strategies that currently exist.
• Although competition among the three professions was cited by some field work participants, there is commonality for the three professions in their positioning in the delivery system. Several examples of collaboration in advocacy efforts between professional groups in States were discussed in the fieldwork.
• At the professional association level, the three professions struggle with the medical profession associations to gain desired recognition, responsibility, and autonomy within their individual scopes of practice. This struggle seems greatest for the advanced nursing professions, although physician assistants encounter many of the same roadblocks. Some of these differences may be attributed to the educational models in which the professions are trained, i.e., nursing models vs. medical models; and some may be attributed to the variation in how legal relationships with physicians are defined, i.e., supervisory, collaborative, consultative, or “independent”.
• The struggles for professional recognition generally address more detailed aspects of practice, suggesting that these professions are maturing. One informant from New York called this period “a time for rationalization”. Whereas statutory and regulatory permission for any prescriptive authority was a prominent issue in the 1990’s, refinement of that privilege is now the focus. The same can be said for legal status and reimbursement.
• This same maturation is occurring in educational programs where standardization of programs across the U.S. continues to be a goal. Growth has slowed in recent years both in the numbers of programs and in the numbers of graduates.
• Another indication of the maturity of the professions is the present concern among all stakeholders about the supply of and demand for these providers presently and in the future. There are even emerging concerns about a possible oversupply of the professions in some States.
• The fieldwork suggested that the three professions contributed significantly to access to care, but it also confirmed that it is not possible to verify statistically the contributions to access made by the three professions because data about their supply, places of practice, and the patients that they treat are inadequate. In fact, the three professions feel that the increased visibility gained through HMO empanelment and direct reimbursement will help to demonstrate their contributions to care for a variety of populations. Use of appropriate provider numbers in all billing for services would distinguish data about who is providing care to underserved populations, clarify the level and kinds of services being provided, and identify the settings in which services are obtained.
• The need for new and continuing incentives to encourage the three professions to practice in health professional shortage areas or with underserved populations was considered important. Among the strategies suggested by the fieldwork participants to increase access to care were: educational loans with payback incentives; the opportunity for increased numbers of clinical rotations in areas where underserved populations are treated; Medicare incentives similar to those provided to physicians practicing in underserved areas; programs for recruitment of new professionals directly from underserved populations; and educational opportunities that are accessible in or near underserved communities

There was a broad consensus across the fieldwork states that professional practice options expanded in the 1990s for all three professions, and that practice is now more uniform across the States. Although more improvements are possible, many strides have been made for all three professions.

The contributions by the three professions to access to care continue to be significant. The primary care orientation of NPs, PAs, and CNMs guides the professions in the provision of both primary and specialty services. There is significant potential for these professions to provide services in places where there are gaps in health care. Direct reimbursement from all payers would be important to achieving greater access for underserved populations. Financial incentives for all of the health professions should be encouraged. Physicians and the three professions work cooperatively and interdependently in a variety of health settings. This should be encouraged since the quality, quantity, and substance of services provided are enhanced by the competencies and skills of each of the professions working interdependently.

Attention should be paid to a variety of factors that influence the supply and distribution of the professions across settings. Clinical rotations, scholarship and loan programs, and pay or tax incentives to work in health settings that provide care to medically underserved populations are important inducements to encourage these professionals to work in those settings.

The three professions are important to provision of quality and cost-effective care to a range of consumers. The skills and competencies of the professions allow them to practice in all health care settings in collaboration with other medical professionals. There is still untapped potential within the professions that could help to resolve some of the significant access issues that exist across States. The paths to achieving this goal are both regulatory and financial.